American College of Physicians: Internal Medicine — Doctors for Adults ®

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Electronic medical records have yet to fulfill their potential

From the October ACP Internist, copyright © 2011 by the American College of Physicians

By Virginia L. Hood, MBBS, MPH, FACP

Like so many of my colleagues, I longed for the emergence of an electronic health record (EHR) that had the potential to transform health care delivery. Over the years, I volunteered for committees promoting this effort but became discouraged by the many barriers. Finally, EHRs arrived, along with the creation of health information technology (HIT) companies that produced, profited from and promoted versions that have been widely distributed to hospitals and outpatient clinics. All promised to reduce errors, increase efficiency and restrain health care costs.

Admittedly, I am not tech-savvy. I find little intuitive about web pages, e-devices and e-media and I'm not a fan of the trial-and-error approach to problem solving, especially as it pertains to health care. However, I was excited about the potential benefit an EHR promised, so when a top-of-the-line version arrived at our institution for inpatient care, I was keen to try it. My initial enthusiasm was quickly dampened when it was introduced in the outpatient clinic. The long training sessions showed me multiple ways to do things I did not need for a patient encounter, without focusing on those that I did.

One physician's experience

The day we went live with our EHR was a nightmare. Even my tech-savvy colleagues were dismayed. I heard that another institution using a similar product had 6,000 “notices” of problems on the first day their system was rolled out to multiple hospital and clinic sites. So what went wrong?

As with any system, an EHR produces the outcome for which it was designed. The most widely used EHRs are designed for auditing, compliance and billing. They are not designed for more efficient patient care in the office, better communication among providers, or the collection of group data for quality improvement efforts. As yet, there is no evidence that the use of an EHR provides less expensive care and/or better outcomes.

Medical record templates do not lend themselves to either recording or reporting meaningful clinical information. Details of a patient's story can be lost in a format that boxes individuals into disease categories, making it hard, for example, to distinguish one person with diabetes from another. Judicious use of cut-and-paste can save time and provide continuity with previous encounters. Poor use of it can perpetuate errors, and such files are often so poorly edited that two contiguous sentences can contradict each other.

Rather than being easier to read and navigate, encounter documents are longer, filled with extraneous information, and often lack the key elements of the physician's thoughts behind the assessment and plan. “Where are those informative notes we used to receive following our patient's visit to subspecialty clinic?” asked one of the community physicians who was swamped by the size and redundancy of the office notes he now receives and must file from consultants. Sadly, this problem affects us all.

After several months, I can now negotiate the system, but it still takes more time, effort, concentration and emotional energy than it should. The satisfaction of the examining-room encounter with my patients is compromised more than I could have possibly imagined. Furthermore, our high-priced EHR cannot import laboratory values from other organizations, is not configured to provide us with group data about blood pressure control and cannot electronically send our records to doctors outside our system with whom we share patient care.

EHR design flaws

One serious barrier to removing design flaws and other software hazards is the typical EHR vendor license, which includes a gag clause that prohibits purchasers and users from sharing information about software problems with anyone outside of their organizations. Such restrictions are an anathema to the development of cooperative enterprises that can find solutions that will facilitate not hinder patient care.

EHRs are not without their pluses. Computerized prescriptions, though not error proof, do seem to be safer than handwritten ones. Though restricted to information entered into the e-record, patient care is enhanced by physicians being able display laboratory values showing the progression of a condition or details, including images, of a disorder that needs addressing. But this is not enough.

Take control of the process

As physicians and physician organizations, we must take control of the electronic medical record. If ever there was an issue that should unite not just internal medicine but all specialties, it is this. The medical record exists first and foremost for the patient and providers to maintain historical information and allow communication among health care team members. Patients are entitled to have health records that are accurate, reflect their problems and are in a format that enables all their doctors to communicate effectively with each other.

We need to insist that anything our institutions purchase for physician use fulfills the criteria for better patient outcomes, patient experience and meaningful use, and that its programmers can transform critical feedback into a better product.

We need programmers to expand on the strengths of EHRs and to make new and existing systems more user-friendly, efficient, and easily accessible when we seek information for quality measures. Patient safety should govern vendor contracts, not intellectual property ownership, liability or gag clauses.

EHRs should be designed so physicians do fewer clerical tasks and more patient-related ones. Physician time is valuable for patients who want to talk with us, hear our explanations and advice and feel assured that someone has an interest in both their disease and their well-being.

ACP's efforts

ACP has been concerned and active in this sphere for some time. The College has information about EHRs and practice improvement, and on related advocacy efforts.

ACP is a founding partner of AmericanEHR Partners, an online community designed to provide all health care professionals with credible information about many different EHRs and a comparison tool to review ratings and features. Eleven medical societies and two more practice management societies provide content. There are now 10,000 registered users and more than 2,500 surveys. There is also information about subjects such as meaningful use and Medicare and Medicaid incentive programs. College staff, Fellows and Masters represent practicing clinicians on the government HIT policy and standards committees and organizations whose purpose is to ensure that new systems are usable, interoperable, safe and effective.

As physicians we have a responsibility to work with others to ensure that EHRs are designed and used to improve patient and physician satisfaction, increase productivity and promote high-value, cost-conscious care. Join me and the College in our efforts to enable this exciting technology to realize its as yet unfulfilled promise.

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ACP leaders share experiences on EHRs, PCMHs

As ACP's president, Virginia L. Hood, MBBS, MPH, an ACP Fellow, notes in this month's column, changes in health care delivery are not always easy for individual physicians and practices. Other ACP leaders who have recently transitioned to electronic health records (EHRs) and patient-centered medical homes (PCMHs) shared their experiences with ACP Internist via e-mail.

Nitin S. Damle, MD, a Fellow of ACP and an ACP Regent, is in an eight-physician practice that first adopted EHRs about 12 years ago. Earlier this year, Dr. Damle's practice applied for National Committee for Quality Assurance PCMH level 3 certification after participating for two years in Rhode Island's all-payer PCMH pilot. The practice was also redesigned to meet meaningful use and accountable care organization (ACO) requirements. Along the way, Dr. Damle said, he and his colleagues encountered three significant challenges:

  1. The level of data entry necessary to meet PCMH, ACO and meaningful use criteria takes time, personnel and money.
  2. Health information exchange is still early in its development. Clinically meaningful data exchange is still in the future.
  3. The ACO model requires primary care physicians to measure the quality and efficiency of their surgical and medical specialty referrals and take financial risk/reward for care management, which adds another layer of complexity.

“The formidable challenge is to scale and translate care of each patient by each physician in the new model of care to improve population health and the quality and the cost of care in the United States,” he said.

Molly Cooke, MD, also a Fellow of ACP and an ACP Regent, described her first day with an EHR:

“All I tried to do in real time were the orders, medications and referrals, because the workflow requires that. The system generates an after-visit summary made up of many elements that in our old system had their own forms. Patients were laughing at me all morning as I tried to figure out how to do things in the new environment. Several of them pulled their chairs around and helped. I never did figure out how to give Tdap without Hib, though I am sure that there is a way.”

Dr. Cooke said that the transition has increased the workload for support staff and slowed things down in the short term. However, she noted, “I can already see some positives. My work feels more interdependent with that of the non-physician staff in the practice and that has to be a very good thing.”

Yul D. Ejnes, MD, a Fellow of ACP and Chair of ACP's Board of Regents, said his practice's recent transition to a PCMH dramatically changed its workflow, expanding the role of medical assistants, adding a nurse care manager, and introducing printed “medical summaries” at checkout for each visit.

Under the new system, Dr. Ejnes said, “It seemed to me that I had more time to talk to the patients.” But, he cautioned, “There will be more changes to come, and whether patients get better care (or think that they get better care) and physicians are happier will need to be studied.”

Information on ACP's positions regarding health information technology and the PCMH is available online.

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